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Dealing with the Emotions of Cancer
A Personal Perspective
Cancer Director Named to newly Endowed Professorship
Research Roundup - Bone Marrow Transplantation:
Targeting Neuroblastoma
Kinder, Gentler Transplants for Older Patients
Harnessing the Immune System - New Bone Marrow Transplant Director Aims High
Cancer Center Offers Post-Treatment Breast Cancer Nutrition Classes
MARCH Deemed a Success!
Spring to Life Benefit
Transplanting Courage
BMT Glossary
U-M Peer Counseling Program
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Dealing with the Emotions of Cancer
New Psycho-Oncology Program Will Offer Solutions
"Am I going crazy?" Cancer patients often ask themselves this
question, but according to psychiatrist Michelle B. Riba,
M.D., M.S., the answer is usually no. "However there are a
lot of reasons to feel overwhelmed and anxious," she explained
at a recent Cancer AnswerNight, "The Blues, the Blahs and
the Pits: Dealing with the Emotions of Cancer."
"The distress is most difficult right at diagnosis and after
treatment is complete, when the person re-enters his or her
normal routine," says Riba.
Emotional distress can be caused by any number of factors,
including uncertainty about the future, pain, side effects
of treatment, feelings of isolation or guilt, information
overload, worries about recurrence, physical limitations,
as well as financial and family problems. In addition, there
may be psychiatric symptoms that pre-date the cancer diagnosis.
Furthermore, patients often don't realize that chemotherapy,
surgery and other treatments can directly cause or contribute
to their psychological condition.
So is it normal for cancer patients to be depressed and anxious?
Riba says depression and anxiety are very common 50 percent
or more of cancer patients have depressed mood or anxiety
or both at various times. Symptoms may include difficulty
concentrating, inability to carry out one's usual daily routine,
intrusive thoughts and fears about their diagnosis and the
future. "But it's very important for people to seek professional
help if these symptoms last for more than a few weeks," she
says.
To help patients better cope with the emotions of cancer,
Riba will lead the new Psycho-Oncology program, a collaborative
effort between the Department of Psychi-atry and the Cancer
Center's Behavioral Oncology program, directed by Bernadine
Cimprich, Ph.D. The Psycho-Oncology program will strive not
only to improve patient care, but also research and health
professional training.
Patient care
At the Cancer Center, psycho-oncology services are provided
by a wide variety of professionals psychiatrists, psychologists,
social workers, nurses, physicians, nurse practitioners, clergy
and education specialists. Patients and their families are
either seen individually or in group settings.
"While most of the groups are either supportive or educational,
our new Psycho-Oncology program plans to expand services by
providing cognitive-behavioral, interpersonal, relaxation
and insight-oriented group therapies," says Riba. "Currently,
groups tend to be diagnosis-based (for example breast cancer
or melanoma), but we plan on looking at common themes (such
as going back to work or marital issues) as a way of providing
additional assistance to patients and families."
Riba cites the work of David Spiegel, M.D., and colleagues
at Stanford University, who published findings that show supportive/expressive
group psychotherapy extended the survival time of patients
with metastatic breast cancer. Since then Riba says there
have been important advances in the relationship of psychiatric
issues and cancer. For example, studies have shown:
- positive effects of psychiatric intervention on recurrence
and survival in malignant melanoma patients;
- reduction of pain in metastatic breast cancer patients
who receive both group therapy and hypnosis; and
- a psychobiological relationship between emotions and the
aggressiveness of certain types of tumors such as gliomas.
Research
According to Riba, researchers have tried for decades to determine
the relationship of such factors as depression, anger, personality
traits, suppression of emotions, stress and others to developing
and surviving cancer. "To date, there have been no large-scale
studies to confirm that any of these factors increase the
likelihood of getting cancer and surviving cancer," she says.
Drawing on the resources of the U-M's Institute for Social
Research, Department of Psychiatry, Mental Health Research
Institute and the Cancer Center, Riba expects to:
- better understand interventions that can help patients adapt to illness;
- develop ways to enhance and measure patients' quality of life;
- improve interventions to change cancer-causing behaviors (e.g., smoking); and
- pioneer psycho-biological research (e.g., studying the psychiatric side effects of standard and new cancer treatments).
Education and Training
Educating medical students, staff, patients and the public
is another key goal of the program. Through ongoing case-conferences
and public seminars on understanding the psychological dimensions
of coping with cancer, Riba plans to heighten awareness of
this important issue. In addition, oncology fellows are now
trained to assess and treat psychiatric symptoms.
Riba hopes the new program will provide the best possible
psychological care for patients; help students and health
care professionals better communicate with patients and families
about emotions; and lead research efforts to understand the
psychological factors that may improve quality of life for
cancer patients and their families.
"So many patients think they are the cause of their anxiety,
or if only they were stronger, they would not feel so depressed,"
explains Dr. Riba."And to complicate matters, many health
care professionals haven't been trained to recognize and treat
these conditions. We plan to change all of that."
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A Personal Perspective
by Michelle B. Riba, M.D., M.S.
My younger sister and I grew up in New York City in the 1950s
and 60s with loving, well-educated parents and a good home.
But what colored and pervaded our lives was our mother's cancer
hospitalizations, treatments, pain and worry.
Throughout it all, my sister and I never met or talked to
her physician. In those days, hospitals had a lot of rules
against children visiting, so even that was difficult.
Our friends hardly knew about our mother's condition. They
didn't ask, and we didn't tell. It felt like a stigma for
all of us. I remember writing an essay for English class on
"Depression and Cancer." The teacher wrote "Good job" but
never talked to me about what I was writing, my family, etc.
I guess I was asking for some help but never got it.
My sister and I were not part of any discussions on what to
expect or how to cope. Our mother was kept in the dark about
her grim prognosis, but I have always wondered if she really
believed what the doctors were telling her in the face of
a worsening physical condition.
It occurred to me then that cancer affects the entire family.
In my own primitive way, I recognized that there was a deep
emotional aspect to cancer and that there was a relative absence
of knowledge or assistance that should have been provided.
My personal experiences have clearly shaped and fueled my
very focused goal, which has been to provide more informed
psychological help for the distress patients and their families
experience when there is a diagnosis of cancer.
In 1991, I was the consulting psychiatrist to the Bone Marrow
Transplant Unit at the University of Connecticut. I remember
one mother of five young children who had come from Massachusetts
for a transplant. Not only was the distance prohibitive for
her family, but her youngest children couldn't visit because
of the strict visiting rules to guard against infection. We
tried in vain to work with the telephone company to use our
BMT unit as a site for what was then a new way to videoconference
so that the patient could see her children.
Today, there is more recognition of the emotional needs of
patients with cancer and their families. I am grateful that
the University of Michigan Cancer Center will be part of this
exciting new frontier.
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Center Director Named to Newly Endowed Professorship
The leadership of Max S. Wicha, M.D., founding director of
the University of Michigan Comprehensive Cancer Center, has
been honored with a newly established endowed professorship
at the U-M Medical School. The naming of Wicha as the first
Distinguished Professor of Oncology recognizes his vision
and commitment in leading the Center from its infancy to one
of the premier centers in the country.
The professorship will be held by the director and used to
support important research programs. While Wicha serves as
director, the professorship will be called the Distinguished
Professorship in Oncology. When he steps down, it will then
be known as the Max S. Wicha, M.D., Distinguished Professorship
in Oncology.
The professorship was established through the
generosity of Mrs. Geneva Maisel Kellman and major pledge
commitments from John and Suzanne Munn, the Parke-Davis Pharmaceu-tical
Research Division of the Warner-Lambert Company, and fund-raising
efforts by the Cancer Center Development Committee.
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Research Roundup: Bone Marrow Transplantation
Targeting Neuroblastoma
Neuroblastoma is one of the most common childhood cancers
and typically strikes children between the ages of 1 and 5.
The disease often begins as a large mass growing along the
backbone or within the abdomen. In more than 70 percent of
cases, the tumor spreads to other parts of the body, such
as the bones or bone marrow. "Despite all of our modern advances
in medicine," says Gregory Yanik, M.D., pediatric oncologist
at the U-M Cancer Center, "only one-quarter of children with
advanced neuroblastoma are cured."
But new hope is being offered by a compound called metaiodobenzylguanidine
(MIBG). In the 1970s, researchers discovered that MIBG reacts
with more than 90 percent of neuroblastomas. Soon after, the
U-M developed a method to trace MIBG throughout the patient's
body using a special scanning process. This technique allows
physicians to identify the exact sites where the neuroblastoma
has spread.
Now U-M physicians, led by Yanik, are using MIBG to improve
the effectiveness of a bone marrow transplant, which has become
the standard treatment for patients with metastatic neuroblastoma.
Typically radiation therapy or chemotherapy is given during
the bone marrow transplant. However, neither treatment is
tumor specific meaning healthy cells are affected along with
tumor cells, which can lead to side effects. By using MIBG,
which is tumor-specific, along with a bone marrow transplant,
physicians at the U-M are able to target and attack only neuroblastoma
cells.
"We hope this treatment will lead to improved survival with
fewer complications for our patients," says Yanik. The University
of Michigan Cancer Center is one of only two centers in the
country using this technique.
Kinder, Gentler Transplants for Older Patients
Before undergoing an allogeneic transplant, cancer patients
are given a high-dose "preparative" regimen of either chemotherapy
or radiation to eliminate any cancerous cells, make room for
new cells and destroy the immune system so it doesn't reject
the new donor cells. But the irony of a bone marrow transplant
is that the very treatment that's being given to save a patient's
life can also lead to serious side effects or even death.
U-M researchers are looking at ways to lower the intensity
of the preparative regimen without lowering its effectiveness.
Based on findings from previous studies, U-M researchers are
now offering a new regimen to patients with hematologic malignancies,
such as leukemia and lymphoma, who are older than 55 and have
less advanced forms of cancer.
"This group of patients is less likely to tolerate the standard
preparative regimen and has a greater chance of developing
complications," says Voravit Ratanatharathorn, M.D., principal
investigator of this study.
Because there should be fewer complications, this approach
will be more cost-effective as well as less taxing on patients.
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Harnessing the Immune System
New Bone Marrow Transplant Director Aims High
A pediatric oncologist who specializes in bone marrow transplantation,
James Ferrara, M.D., believes the cure for many cancers lies
in making the immune system our "faithful ally."
"The immune system is very powerful and very smart, but unreliable
when it comes to fighting cancer," says Ferrara, professor
of Medicine and Pediatrics, and newly appointed director of
the U-M's Bone Marrow Transplantation Program. "We need to
figure out how to make the immune system work the way we want
it to, which I believe will lead to a cure faster than figuring
out how to trick cancer cells into dying."
James (Jamie) Ferrara did not take the typical route from
undergraduate to medical student. Instead, he studied the
classics for several years at Oxford in England, before getting
his medical degree at Georgetown University. Ferrara says
studying the classics, in particular ancient ethics systems,
has made him a better doctor.
"The ancient Greeks were passionate about life, and studying
their culture helps one understand what it means to live 'the
good life'," he explains. "I learned that the individual counts
and that ideas really matter."
After medical school, Ferrara went on to train at Children's
Hospital and the Dana Farber Cancer Institute in Boston, which
is where he first became interested in bone marrow transplantation
a relatively new therapy at that time. He stayed in the Boston
area, most recently serving as associate professor of Pediatrics
at Harvard Medical School.
For a number of years, Ferrara's research has focused on gaining
a better understanding of the biological mechanisms of graft-versus-host
disease and graft-versus-tumor effects in leukemia patients.
Physicians know that a mild case of graft-versus-host disease
an immune reaction caused when lymphocytes transplanted from
a donor (the graft) reject the patient's body (the host) is
a positive sign that the patient's leukemia is less likely
to recur. A type of white blood cell called a T cell is thought
to be responsible for this anti-leukemia effect, in conjunction
with cytokines (special proteins) that are produced by the
patient's body.
The goal of Ferrara's research is to harness the power of
the graft-versus-tumor effect, while minimizing the potentially
life-threatening consequences of advanced graft-versus-host
disease.
"Years of laboratory research into this field have produced
some very exciting results that are ready to be translated
to the clinical setting where they can benefit our patients,"
says Ferrara. "I decided to come to the University of Michigan
because I felt this was the best place in the country to do
that."
One exciting area of investigation focuses on using the body's
own wisdom to reduce the toxicity of transplant. Normally
a protein in our blood called Interleukin 1 receptor antagonist
(IL-1ra) reduces inflammation. Ferrara's research has shown
that the level of the protein drops to about 20 percent of
normal shortly after transplant and is significantly lower
in patients with graft-versus-host disease (GVHD).
Laboratory research has shown that giving IL-1ra for 10 days
can largely prevent GVHD. A randomized study with patients
is now under way comparing standard treatment plus or minus
IL-1ra. "We're very encouraged because the incidence of GVHD,
particularly severe disease, seems to be reduced," he says.
In addition to his duties as a physician and researcher, Ferrara
plans to make a number of changes to the program in his role
as director.
"One of the challenges a wonderful change really is that we
are combining the adult and pediatric transplant programs,"
says Ferrara. "The pieces are in place because the physicians'
offices are next to each other and they work on the same teams,
but they haven't truly integrated. I think doing so will improve
the standard of care across the board."
Ferrara also will focus on building the areas of research
and education. "The patient care here is excellent we perform
more than 200 transplants each year but we can improve in
our research and education. I'm looking forward to bringing
on additional investigators, as well as improving training
of physicians who will become the next generation of leaders
in this field," Ferrara says.
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Cancer Center Offers Post-Treatment Breast Cancer Nutrition Classes
The flood of information about the relationship between cancer
and diet can overwhelm cancer patients who have many other
issues to think about during treatment. To help patients sort
nutrition fact from fiction, the Cancer Center's Nutrition
Services will offer classes to our breast cancer patients
after they have completed their treatment, when they are better
able to make lifestyle changes.
We will begin with breast cancer patients, but plan to offer
classes for other patients in the future. Each course will
include cooking classes, education about cancer-fighting foods
and information about healthful lifestyle changes. The first
six-week course begins April 13, and classes will meet every
Tuesday from 1 to 3 p.m., at East Ann Arbor Health Center,
4260 Plymouth Road, Ann Arbor.
The cost for a six-week course is $150 (scholarships are available).
To register, call Mary McCully at (734) 936-8307. Please note
that class size is limited to 20 participants. Martha DeRoeck,
M.S., R.D., Cancer Center Dietitian.
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MARCH Deemed a Success!
For the first time, millions of Americans came together to
fight the oldest, most-threatening disease known to man. On
Sept. 25 and 26, cancer survivors, their families and friends
united for a single, unprecedented effort: a rally in Washington,
D.C., to demonstrate the need for increased funding for cancer
research and treatment.
In conjunction with The MARCH: Coming Together to Conquer
Cancer activities held in the nation's capital, the U-M Comprehensive
Cancer Center sponsored several events for the local community.
Display booths were set up on the Mall in Washington with
information on everything from pet therapy to the latest advances
in cancer research. On the main stage, Aretha Franklin sang
"When you Walk Through a Storm;" Jesse Jackson implored the
crowd to change "Pain to Power;" and the honorary MARCH chairman,
H. Norman Schwarzkopf, called on Congress to make the cause,
the care and the cure for cancer a top national priority.
A highlight of the national event was the unveiling of the
National Childhood Cancer Awareness Quilt. Cindy Crawford,
whose brother died of cancer 20 years ago, helped to unfold
the Wisconsin quilt. Dozens of quilts from across the nation
were displayed with the faces of children who were still immersed
in their battle with cancer, had finished their treatment,
or had lost their fight.
More than 300 people attended the Candle Lighting for Hope
and Remembrance at the U-M Cancer Center's front entrance
on Sept. 25, 1998. Families from throughout Michigan shared
more than 800 names of loved ones who had died from cancer.
On Sept. 26, 100 cancer survivors - joined by Michigan's First
Lady Michelle Engler, Mrs. Cathy Schembechler and Mrs. Laurie
Carr - took the field with the Michigan Marching Band during
a pre-game rally at the Michigan Stadium to raise awareness of cancer issues.
The marchers, representing all ages and types of cancers, formed
the international sign "against" as the band played "Lean On
Me." Planes circling overhead carried banners encouraging people
to become advocates in the fight against cancer. The stadium
announcer reminded fans that only one penny out of every $10
we send to Washington, D.C., is spent on cancer research. When
the marchers left the field, the crowd of more than 110,000
chanted along with the U-M cheerleaders "No More Cancer!"
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Spring to Life Benefit
Ford Motor Company Partners with U-M
The University of Michigan Comprehensive Cancer Center and
Ford Motor Company have joined forces to host the ninth annual
Spring to Life Brunch and art auction, which will be held
at noon on Sunday, April 18, at the Morris Lawrence Building
on the campus of Washtenaw Community College.
The benefit committee has been gathering a beautiful variety
of art, including photography, jewelry, glass and paintings
for this year's auction. Look for preview showings March 23
through April 10 at the Selo/Shevel, DeBoer and Chris Triola
galleries in Ann Arbor and at Jacobson's in Briarwood Mall.
The always-incredible brunch will be prepared by The Common
Grill, Food For All Seasons, The Moveable Feast, Cousins Heritage
Inn and award-winning chef Gary Danko.
Tickets for this year's event are $85/person ($60 tax-deductible
gift) as a Donor, $150/person ($125 tax-deductible gift) as
a Sponsor, or $250/person ($225 tax-deductible gift) as a
Benefactor.
To make reservations or for more information, call Janet Roth
or Kelley Altese at (734) 764-7170.
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Transplanting Courage
Danielle Popp was diagnosed with chronic myelogenous leukemia
when she was six months pregnant. Her obstetrician noticed
an elevated white blood cell count during her 26-week glucose-screening
test. Referred to a hematologist/oncologist, Danielle began
her journey as a cancer survivor. "At the time I had no idea
what type of doctor that was or what those words meant. I
was so wrapped up in being pregnant it did not even occur
to me to ask," explains Danielle, age 28.
After deciding with her doctors that the best treatment option
would be a peripheral blood stem cell transplant, Danielle's
three brothers were tested to see if they would be compatible
donors. Her brother Mark in California was found to be a perfect
match.
Doctors continued following Danielle's counts. As long as
her counts stayed stable, they would follow her until her
due date. "So we waited. Every week my counts stayed at 35,000
I felt normal, very healthy," Danielle explains.
On May 22, 1997, Danielle delivered a healthy six pound, 13
ounce baby boy named Jacob. She nursed him for six weeks,
and then overnight, her WBC count shot up to 50,000. Her hematologist
in consultation with transplant doctors at the U-M Comprehensive
Cancer Center decided to put Danielle on Hydrea_ to temporarily
lower her counts until the transplant. The transplant needed
to be done within the first year of diagnosis, and Danielle
and brother Mark decided they would do it after the summer
in September.
After Labor Day, Danielle was admitted to the U-M Hospital.
Her brother arrived that same day from California. After a
week of "conditioning" chemotherapy for Danielle and growth
factor injections for Mark, the transplant was performed on
Sept. 10. Stem cells were harvested from Mark by apheresis
and transfused into Danielle through a central line in her
chest.
According to Danielle, "The transplant was done right in my
inpatient room on the transplant floor, just like a blood
transfusion, very anticlimactic. My whole family was there."
Her family was also there for her throughout treatment and
the many months of recovery. Mark moved in with Danielle and
her husband to take care of Jacob and drive Danielle back
and forth to the hospital for her checkups. Other family members
were always there to offer support and encouragement.
Danielle found even more support on the Internet, on the Bone
Marrow Transplant Talk List. She connected with more than
30 people who lived in different states. Danielle took her
laptop computer with her everywhere, especially when she was
an inpatient.
"If something strange was happening, I would put out a question
on e-mail. Within a few hours, when I was ready to log back
on, the answer was there," says Danielle. "The people online
are just amazing. If they haven't had a similar experience,
they have some other circumstance that fits. I found a lot
of support from that list." She continues to correspond with
many of these "cyber friends" to this day.
On the one-year anniversary of her transplant, Danielle decided
to give something back for all the people who had supported
her through her journey; she volunteered to become a peer
counselor at the U-M Cancer Center. After a one-hour interview
and a four-hour training and orientation session, Danielle
was ready to share her experience with others in active treatment.
"We talk a lot about how I had a hard time going into the
hospital when I was feeling normal whatever normal is to ultimately
make myself so very sick so I could get well," explains Danielle.
"I had to struggle with that for a long time. The person I'm
counseling is experiencing the exact same thing right now."
Possible hair loss, unrealistic expectations and coping with
fatigue are other topics Danielle discusses.
"I found a lot of reassurance from the people I met online.
Knowing that someone had been there, done it and survived
someone else had experienced everything that I was experiencing.
I think that is a huge part of the battle positive attitude
got me through! I hope to pass that on to the people I counsel."
Danielle believes that attitude is 90 percent of the battle,
and she hopes to spread that message to everyone.
Maxine Solvay
Promotion Coordinator
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Glossary
(From
Understanding Your Transplant,
a publication of the U-M Cancer Center)
Apheresis - A blood-separating procedure
in which blood is removed from a patient, sent through a special
machine (where cells are separated and some are removed) and
the remainder returned to the patient.
Conditioning - The purpose of conditioning is to
give high enough doses of chemotherapy and/or radiation to
eliminate any cancerous cells that are present, to make room
for the new cells and to destroy the immune system. This is
done to prevent rejection of the new donor cells.
Growth Factor - an injectable drug used to
stimulate the development of blood cells.
Peripheral Blood - circulating blood system.
Stem Cells - parent or seed cells in the
bone marrow or circulating blood that produce all the different
types of blood cells: white blood cells, platelets and red
blood cells.
Transfusions - the infusion of any product
derived from blood cells.
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The Peer Counseling Program
at the U-M Comprehensive
Cancer Center matches patients with peer counselors according
to diagnosis, treatment and lifestyle. Peer counselors share
their experiences and insights with patients, and can listen
and respond to fellow cancer survivors in a way no other health
professional is able. For information on the Peer Counseling
program, call the U-M Cancer Center Social Work office at
(734) 764-3140.
"Being a peer counselor is probably as helpful to me as to
the person I am counseling - knowing that I am helping someone,
being there and making a difference in a positive way. It
is my way of giving back."
- Danielle Popp
Cancer Survivor
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Editor
Max S. Wicha, M.D.
Director, U-M Cancer Center
Maria White
Director, Marketing Communications
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